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      Chronic lateral epicondylitis: challenges and solutions

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          Abstract

          Lateral epicondylitis (LE) is a significant source of pain and dysfunction resulting from repetitive gripping or wrist extension, radial deviation, and/or forearm supination. Although most cases are self-limiting over several years, controversy exists regarding the best treatment strategy for chronic LE. Nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), shockwave therapy, and injections with corticosteroids or biologics are all conservative treatment options for LE. For refractory cases, surgical options include open, arthroscopic, and percutaneous techniques. In this review, the current evidence behind these treatment strategies is presented. The data demonstrate that NSAIDs, PT, bracing, and shockwave therapy provide limited benefit for treating LE. Biologics such as platelet-rich plasma and autologous whole-blood injections may be superior to steroid injections in the long-term management of LE. Although the initial results are promising, larger comparative studies on stem cell injections are needed. For refractory LE, open, arthroscopic, and percutaneous techniques are all highly effective, with no method seemingly superior over another. Arthroscopic and percutaneous approaches may result in faster recovery and earlier return to work.

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          Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up.

          Platelet-rich plasma (PRP) has shown to be a general stimulation for repair. Purpose To determine the effectiveness of PRP compared with corticosteroid injections in patients with chronic lateral epicondylitis. Randomized controlled trial; Level of evidence, 1. The trial was conducted in 2 teaching hospitals in the Netherlands. One hundred patients with chronic lateral epicondylitis were randomly assigned in the PRP group (n = 51) or the corticosteroid group (n = 49). A central computer system carried out randomization and allocation to the trial group. Patients were randomized to receive either a corticosteroid injection or an autologous platelet concentrate injection through a peppering technique. The primary analysis included visual analog scores and DASH Outcome Measure scores (DASH: Disabilities of the Arm, Shoulder, and Hand). Successful treatment was defined as more than a 25% reduction in visual analog score or DASH score without a reintervention after 1 year. The results showed that, according to the visual analog scores, 24 of the 49 patients (49%) in the corticosteroid group and 37 of the 51 patients (73%) in the PRP group were successful, which was significantly different (P <.001). Furthermore, according to the DASH scores, 25 of the 49 patients (51%) in the corticosteroid group and 37 of the 51 patients (73%) in the PRP group were successful, which was also significantly different (P = .005). The corticosteroid group was better initially and then declined, whereas the PRP group progressively improved. Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and significantly increases function, exceeding the effect of corticosteroid injection. Future decisions for application of the PRP for lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible costs and harms as well as benefits.
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            Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up.

            Platelet-rich plasma (PRP) has been shown to be a general stimulation for repair and 1-year results showed promising success percentages. This trial was undertaken to determine the effectiveness of PRP compared with corticosteroid injections in patients with chronic lateral epicondylitis with a 2-year follow-up. Randomized controlled trial; Level of evidence, 1. The trial was conducted in 2 Dutch teaching hospitals. One hundred patients with chronic lateral epicondylitis were randomly assigned to a leukocyte-enriched PRP group (n = 51) or the corticosteroid group (n = 49). Randomization and allocation to the trial group were carried out by a central computer system. Patients received either a corticosteroid injection or an autologous platelet concentrate injection through a peppering needling technique. The primary analysis included visual analog scale (VAS) pain scores and Disabilities of the Arm, Shoulder and Hand (DASH) outcome scores. The PRP group was more often successfully treated than the corticosteroid group (P < .0001). Success was defined as a reduction of 25% on VAS or DASH scores without a reintervention after 2 years. When baseline VAS and DASH scores were compared with the scores at 2-year follow-up, both groups significantly improved across time (intention-to-treat principle). However, the DASH scores of the corticosteroid group returned to baseline levels, while those of the PRP group significantly improved (as-treated principle). There were no complications related to the use of PRP. Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and increases function significantly, exceeding the effect of corticosteroid injection even after a follow-up of 2 years. Future decisions for application of PRP for lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible costs and harms as well as benefits.
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              Tennis elbow. The surgical treatment of lateral epicondylitis.

              Of the 1,213 clinical cases of lateral tennis elbow seen during the time period from December 19, 1971, to October 31, 1977, eighty-eight elbows in eighty-two patients had operative treatment. The lesion that was consistently identified at surgery was immature fibroblastic and vascular infiltration of the origin of the extensor carpi radialis brevis. A specific surgical technique was employed, including exposure of the extensor carpi radialis brevis, excision of the identified lesion, and repair. The results at follow-up were rated as excellent in sixty-six elbows, good in nine, fair in eleven, and failed in two. There was an over-all improvement rate of 97.7 per cent, and 85.2 per cent of the patients returned to full activity including rigorous sports.
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                Author and article information

                Journal
                Open Access J Sports Med
                Open Access J Sports Med
                Open Access Journal of Sports Medicine
                Open Access Journal of Sports Medicine
                Dove Medical Press
                1179-1543
                2018
                30 October 2018
                : 9
                : 243-251
                Affiliations
                [1 ]David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
                [2 ]Rothman Institute, New York, NY, USA
                [3 ]IHA Orthopaedic Specialists, Ann Arbor, MI, USA
                [4 ]Department of Orthopaedic Surgery, UC Irvine Health, Orange, CA, USA, deanwangmd@ 123456gmail.com
                Author notes
                Correspondence: Dean Wang, Department of Orthopaedic Surgery, UC Irvine Health, 101 The City Drive South, Pavilion III, 2nd Floor, Orange, CA 92868, USA, Email deanwangmd@ 123456gmail.com
                Article
                oajsm-9-243
                10.2147/OAJSM.S160974
                6214594
                30464656
                d6b2e087-2599-423f-a85d-f1d8be407809
                © 2018 Lai et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                lateral epicondylitis,tennis elbow,shockwave,injection,biologics,platelet-rich plasma,stem cells,surgery

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